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Pelvic mass

Pelvic mass. Jonathan Blankenstein and Amy Toderian. Objectives. 4233 List pelvic tumors of ovarian origin. 4234 Classify ovarian pathology as benign vs malignant. 4396 Compare and contrast functional vs neoplastic ovarian cysts. Case.

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Pelvic mass

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  1. Pelvic mass Jonathan Blankenstein and Amy Toderian

  2. Objectives • 4233 List pelvic tumors of ovarian origin. • 4234 Classify ovarian pathology as benign vs malignant. • 4396 Compare and contrast functional vs neoplastic ovarian cysts.

  3. Case • An 18 year old woman presents to your office for routine gynecologic examination.

  4. History • What do you need to ask?

  5. History • GyneHx Review • ID: age, occupation, relationship with partner, gravida, parity • Menstrual Hx: age at menarche, characterize menstrual cycle, LMP, age at menopause, use of HT, dysmenorrhea • Sexual Hx: Age at first intercourse, partners, types of sexual activity, previous STIs, use of precautions (pregnancy and STIs), dyspareunia • Pap smear Hx: date of last pap, abnormal paps and follow up, HPV

  6. History • HPI: She reports that her last menstrual period began about 23 days ago. It was light in flow, and lasted 4 days in length. She has minimal dysmenorrhea. She denies any history of sexually transmitted infections, and has been sexually active with two male partners in the last 2 weeks. She has no children, and has never been pregnant. She was given a prescription for OCP 3 months ago. • ROS: No concerns.

  7. History • MEDS: None – has not filled OCP prescription • ALLERGIES: None • PMX: Healthy with no hospitalizations or surgeries. • Immunizations: Up to date, Gardasil • FHx: Non-contributory • SHx: Lives at home with mom, dad and younger brother. Mom is a teacher and Dad is a government worker. Has a part-time job at Walmart. Attends U of O. Has private health insurance and drug coverage through Dad. Denies being in a relationship.

  8. Physical Exam • OMG, now what?

  9. Physical Exam • GENERAL: Alert and oriented, no visible distress, healthy glow. • VITALS: HR 60 RR 12 BP 110/74 T 36.5 spO2 100% • External exam: Normal female genitalia. • Speculum exam: No visible abnormalities, no blood or discharge • Pelvic exam: 6 cm nontender left adnexal mass that is mobile • Abdo exam: No rebound, guarding or tenderness

  10. DDx Adnexal Mass • Ovarian mass • Physiologic (functional) cyst • Benign ovarian neoplasm • Ovarian cancer or metastatic disease • Extra-ovarian mass • Tubo-ovarian abscess, hydro/pyosalphinx, ectopic pregnancy, appendiceal abscess, diverticular abscess, inflammatory bowel disease, fallopian tube malignancy, fibroids

  11. Physiologic cysts • “Post-menarchal-premenopausal, small, transient”

  12. Physiologic cysts • “Post-menarchal, premenopausal, small, transient”

  13. Benign Ovarian Neoplasms • What’s this?

  14. Benign Ovarian Neoplasms

  15. Benign Ovarian Neoplasms

  16. Benign Ovarian Neoplasms

  17. Benign Ovarian Neoplasms • Teratoma – germ cell tumor with ectodermal predominance, 90% of ovarian tumors in young women, removed surgically when > 8 cm. • Endometrioma – growth of ectopic endometrial tissue, 20% of endometriosis presentations, associated with dysmenorrhea, pelvic pain, dyspareunia, and/or infertility • Serous cystadenoma – Arises from surface epithelium, common in middle adult life, papillary epithelium is contained within a fibrous walled cyst filled with serous fluid, • Mucinous cystadenoma– Arises from surface epithelium, common in middle adult life, multiloculatedwith sticky gelatinous fluid rich in glycoproteins

  18. Ovarian malignancies • NEED TO RULE THIS OUT

  19. Ovarian malignancies • NEED TO RULE THIS OUT • Increased risk of malignancy: • Prepubescent or postmenopausal female • A complex or solid appearing mass (on imaging) • Known genetic predisposition (BRCA) • Presence in a woman known to have a nongynecological cancer (eg, breast or gastric cancer)

  20. Ovarian malignancies

  21. Ovarian metastases Sites of origin of the primary: • Breast – 30% • GI Tract – 20% • Endometrium • Lung • Kidney Spreads by direct invasion, surface implantation, lymphatics, blood.

  22. Investigations – Imaging • The next step is ultrasound • Transabdominal, Transvaginal, Doppler • Simple Cyst, Complex Cyst, Solid • (Don’t do an X-Ray) • CT or MRI reserved for special cases

  23. Investigations – Lab • CBC w Diff • Beta hCG • CA 125 • Other tumor markers • AFP, hCG, LDH

  24. Benign vs Malignant

  25. RMI = a x b x c a b c >200 = high risk of malignancy

  26. Management • Observation (+f/u) • Suppression • Surgery/Excision • Referral to GyneOnc Not worried Worried

  27. When to Consider Surgery: • Emergency surgical management is indicated in: • Torsion • Ectopic pregnancy • Appendiceal abscess • Ruptured TOA • Hemorrhagic cyst with hemodynamic instability • Not emergency surgery is indicated when: • Simple Cyst (Persistent, Mass Effect, Enlarging) • Complex Cyst (Persistent, Mass Effect, Annoying) • Solid Cyst (especially if obstructing!)

  28. When to Consider GyneOnc: …high risk of underlying malignancy

  29. Case revisited • What if this were our patient?

  30. Management of post-menopausal pelvic mass • Cancer until proven otherwise! Same approach: • History • Physical • U/S • CA 125 • RMI

  31. Thank You!

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